Intraoperative Decision Research Articles

Clinical Profile and Surgical Management of Intramedullary Spinal Cord Tumors

Background and Aim: Intramedullary spinal cord tumors (IMSCTs) are rare tumors of the spine. The study aims to analyze the clinical profile and surgical management of IMSCTs. Methods and Materials/Patients: This is a retrospective study to review the IMSCTs operated between January 2007 to December 2021. Myxopapillary ependymomas were excluded from the study. Results: There were twenty-seven operated cases of IMSCTs. The Mean±SD age was 39±22 years. Fifteen (55.5%) were males and 12(44.5%) were female patients. There were 6(22%) cervical, 7(26%) cervicodorsal, 9 (33%) dorsal, and 5(19%) dorsolumbar IMSCTs. The Mean±SD duration of symptoms was 10±14 months. Ten (37%) patients had spinal cord syrinx. Motor weakness and pain were the most common symptoms. Intraoperative gross total resection (GTR) was achieved in 12(44.4%) patients, near-total resection in 4(14.8%) patients, subtotal resection in 2(7.4%) patients, decompression in 7(26%) patients, and biopsy in 2(7.4%) patients. Eighteen (66.6%) patients had neurological status same as preoperative status. Four (14.8%) patients had improvement and 5(18.5%) patients had deterioration in neurological status. Ependymoma was the most common histological type of IMSCT (40.5%). Other lesions are glioma, hemangioblastoma, lipoma, schwannoma, lymphoma, capillary hemangioma, arachnoid cyst, and epidermoid cyst with spinal dysraphism. Ependymomas had well-defined margins compared to other gliomas. Duration of stay in the hospital was 9±3.5 days. Conclusion: Dorsal spine is the most common location of IMSCTs and ependymoma is the most common histological type. It is the surgeon’s intraoperative decision regarding the extent of resection of the tumor based on the spinal cord infiltration and tumor type. GTR is possible in the majority of ependymomas and some other histological tumors like schwannoma, arachnoid cyst, and epidermoid cyst.

Utility of intraoperative Delphian lymph node sampling in pediatric thyroid surgery

ObjectivesThe Delphian lymph node (DLN) is the first lymph node receiving drainage from the thyroid. We aim to determine whether routine DLN sampling with frozen section analysis during pediatric thyroidectomy can alter intraoperative surgical decision making. Additionally, we aim to measure whether DLNs can predict a requirement for central neck dissection (CND) in the clinically node negative (CNN) pediatric population. MethodsRetrospective chart review for pediatric patients who underwent thyroidectomy between 2014 and 2022. Patients were included if they had prior FNA with a result of: benign nodule, atypia or follicular neoplasm of undetermined significance (AUS/FNUS), follicular neoplasm (FN), or papillary thyroid carcinoma (PTC). All patients had intraoperative DLN analysis via frozen section histopathology. Results27 patients were included, 9 males (33 %) and 18 females (67 %). On final pathology 19 patients (70.4 %) had PTC. The DLN was negative for carcinoma in all (n = 8, 100 %) patients with benign pathology. In 10 patients (100 %) with positive DLN on frozen section, postoperative pathology demonstrated central neck metastasis. Nine (90 %) of these patients were CNN and had alterations in the surgical plan based on the DLN. The tenth patient's surgical plan did not change given preoperative clinical disease. Three patients with negative DLNs had central neck metastasis. ConclusionThe DLN serves a role in guiding treatment for the pediatric population. Positive DLN altered surgical plans in 60 % of CNN PTC patients, allowing for CND to be performed and reducing need for additional surgical resection. The positive predictive value for DLN status was 100 % in this study, and the negative predictive value was 62.5 %. However, negative DLNs do not rule out central neck disease.

Variable practice patterns in the surgical management of renal hyperparathyroidism

BackgroundHyperparathyroidism is common among patients with chronic kidney disease, end-stage kidney disease, and kidney transplant. The American Association for Endocrine Surgery published clinical practice guidelines that address the surgical treatment of secondary and tertiary hyperparathyroidism. The purpose of this study is to determine practice patterns for the surgical management of secondary and tertiary hyperparathyroidism prior to guideline publication. MethodsWith the approval of the American Association for Endocrine Surgery, a Qualtrics email survey was sent to the Association’s membership in 2022 about current clinical decision making for surgical treatment of secondary and tertiary hyperparathyroidism. Respondents were divided into groups based on surgical subspecialty (endocrine surgery versus non-endocrine surgery), yearly parathyroidectomy volume, and yearly parathyroidectomy volume for surgical treatment of secondary and tertiary hyperparathyroidism. Descriptive statistics were performed; the role of volume was evaluated. ResultsThere were 142 responses from 795 solicited email addresses (18% response rate); 114 (84%) identified as endocrine surgeons. The majority (62%) perform >50 parathyroidectomies yearly, but most perform <10 parathyroidectomies for surgical treatment of secondary and tertiary hyperparathyroidism per year (<10/y, 53.7%; 10–30/y, 41.9%; >30/y, 4.4%). Subtotal parathyroidectomy is most commonly performed for surgical treatment of secondary (83%) and tertiary (52%) hyperparathyroidism, but transcervical thymectomy variably performed for both. There was no consensus regarding starting calcitriol preoperatively (always 43%, never 25%, depends on vitamin D levels 24%) or stopping cinacalcet (2 weeks prior 28%, day of surgery 29%, postoperatively 20%). Surgeons who perform >10 parathyroidectomies per year for surgical treatment of secondary and tertiary hyperparathyroidism were less likely to consider the patient's preoperative vitamin D levels to inform their decision to start calcitriol before surgery (<10 cases/year, 34%; ≥10 cases/year 15%; P = .023), were more likely to have a postoperative hypocalcemia protocol managed by the surgical team (<10 cases/year, 49%; ≥10 cases/year, 58%; P = .029), and were more likely to use intraoperative parathyroid hormone monitoring for tertiary hyperparathyroidism (<10 cases/year, 70%; ≥10 cases/year, 87%; P = .046). ConclusionThe majority of respondents perform <10 parathyroidectomies yearly for surgical treatment of secondary and tertiary hyperparathyroidism. Subtotal parathyroidectomy was most commonly performed, but there was little other consensus regarding preoperative management, intraoperative decision-making, and postoperative care. Opportunity exists through guideline dissemination to improve heterogeneity of care provided to surgical treatment of secondary and tertiary hyperparathyroidism patients.

Osteoporosis May Not Be an Absolute Contraindication for Cementless Total Knee Arthroplasty

BackgroundCementless total knee arthroplasty (TKA) has received growing interest, particularly in younger populations, due to potential long-term survivability and improved bone preservation. Poor bone stock, as seen in osteoporosis, is considered a contraindication for this technique. This study evaluated whether osteoporotic patients < 75 years undergoing cementless TKA demonstrate similar 1) implant-related complications, 2) medical complications, 3) readmission rates, and 4) 3-year implant survivability. MethodsA retrospective query of a national administrative claims database was performed between 2010 and 2022 for patients less than or equal to 75 years old who have osteoporosis and underwent primary TKA. Osteoporotic patients were divided into cementless and cemented cohorts, and propensity scores were matched based on age, sex, obesity, and the Charleston Comorbidity Index (CCI). Matching produced 7,923 patients (1,321 uncemented, 6,602 cemented). Multivariate logistic regressions evaluated the following outcomes: 90-day and 2-year implant-related complications, 90-day postoperative medical complications, and 90-day readmissions. Kaplan-Meier survival analysis was conducted to assess 3-year all-cause revision implant survivability. The significance threshold was set to P < 0.01 to minimize type 1 bias. ResultsThere were no statistically significant differences in implant-related complications, medical complications, readmissions, and lengths of stay between cementless and cemented TKA groups. Kaplan-Meier analysis demonstrated statistically similar 3-year survivability between cohorts (cemented: 97.6%, CI [confidence interval] 96.6 to 98.5; cementless: 97.2%, CI 96.7 to 97.7; P = 0.472). ConclusionPatients who have osteoporosis have equivalent medical and implant-related complications as well as 3-year implant survival following cementless TKA compared with a cemented technique. Our results support cementless TKA as a viable option for patients < 75 years, regardless of prior diagnosis of osteoporosis. Intraoperative decisions regarding bone quality are still necessary to discriminate between those who are candidates for cementless TKA with those who are not.

Reevaluation of Recipient Vessel Selection in Breast Free Flap Reconstruction.

Current consensus has established the internal mammary vessels (IMV) over the thoracodorsal vessels (TDV) as the preferred recipients for microvascular breast reconstruction due to their superior flow rates and long-established outcomes. Yet, there are occurrences where the IMVs are not reliable and may subsequently prompt intraoperative decision-making. Several options exist, including the contralateral IMVs, thoracoacromial vessels, and TDVs. The appropriate sequence for vessel choice is not universally agreed upon. This study reevaluates the TDVs to highlight their viability as a second-line intraoperative alternative to the IMV and provide reference to the straightforward dissection required for harvest. A retrospective, single-institution, breast-level analysis examining 4754 breast free flaps from 2978 patients undergoing bilateral free flap reconstruction was conducted. Postoperative complications within 180 days were evaluated, and cohorts based on anatomic anastomosis (IMV vs. TDV) were created to compare outcomes. Subanalysis was conducted based on flap laterality as well as whether a flap was planned or converted intraoperatively. Of 4754 breast free flaps, 4269 (89.8%) used the IMV while 485 (10.2%) used the TDV. Most complication rates between the TVD and IMV were not significantly different. Rates of flap loss were 1.0% and 1.2% for the IMV and TDV anastomosis (p = 0.59). IMV and TDV anastomosed flaps experienced similar rates of fat necrosis (6.3% vs. 6.2%, p = 0.915). However, multivariable analysis of all breasts regardless of laterality showed that skin necrosis was significantly less likely in TDV breasts (OR 0.45, 95% CI 0.29-0.71, p < 0.001). Given the relative similarity in cohort outcomes, TDV anastomosis can be considered a viable alternative to the IMV when the IMV is unavailable or technically disadvantageous. The TDV artery remains a robust and reliable option in the present-day plastic surgeon's repertoire for breast reconstruction.

Contrast-Enhanced Intraoperative Ultrasound Shows Excellent Performance in Improving Intraoperative Decision-Making.

The aim of this study was to evaluate the performance and the impact of contrast-enhanced intraoperative ultrasound (CE-IOUS) on intraoperative decision-making, as there is still no standardized protocol for its use. Therefore, we retrospectively analyzed multiple CE-IOUS performed in hepato-pancreatic-biliary surgery with respect to pre- and postoperative imaging and histopathological findings. Data of 50 patients who underwent hepato-pancreatic-biliary surgery between 03/2022 and 03/2024 were retrospectively collected. CE-IOUS was performed with a linear 6-9 MHz multifrequency probe connected to a high-resolution device. The ultrasound contrast agent used was a stabilized aqueous suspension of sulphur hexafluoride microbubbles. In total, all 50 lesions indicated for surgery were correctly identified. In 30 cases, CE-IOUS was used to localize the primary lesion and to define the resection margins. In the remaining 20 cases, CE-IOUS identified an additional lesion. Fifteen of these findings were identified as malignant. In eight of these cases, the additional malignant lesion was subsequently resected. In the remaining seven cases, CE-IOUS again revealed an inoperable situation. In summary, CE-IOUS diagnostics resulted in a high correct classification rate of 95.7%, with positive and negative predictive values of 95.2% and 100.0%, respectively. CE-IOUS shows excellent performance in describing intraoperative findings in hepato-pancreatic-biliary surgery, leading to a substantial impact on intraoperative decision-making.

Informing Decision-making for Transected Margin Reresection in Intraductal Papillary Mucinous Neoplasm-derived PDAC: An International Multicenter Study.

To assess the prognostic impact of margin status in patients with resected intraductal papillary mucinous neoplasms (IPMN)-derived pancreatic ductal adenocarcinoma (PDAC) and to inform future intraoperative decision-making on handling differing degrees of dysplasia on frozen section. The ideal oncologic surgical outcome is a negative transection margin with normal pancreatic epithelium left behind. However, the prognostic significance of reresecting certain degrees of dysplasia or invasive cancer at the pancreatic neck margin during pancreatectomy for IPMN-derived PDAC is debatable. Consecutive patients with resected and histologically confirmed IPMN-derived PDAC (2002-2022) from six international high-volume centers were included. The prognostic relevance of a positive resection margin (R1) and degrees of dysplasia at the pancreatic neck margin were assessed by log-rank test and multivariable Cox-regression for overall survival (OS) and recurrence-free survival (RFS). Overall, 832 patients with IPMN-derived PDAC were included with 322 patients (39%) having an R1-resection on final pathology. Median OS (mOS) was significantly longer in patients with an R0 status compared to those with an R1 status (65.8 vs. 26.3mo P<0.001). Patients without dysplasia at the pancreatic neck margin had similar OS compared to those with low-grade dysplasia (mOS: 78.8 vs. 66.8 months, P=0.344). However, high-grade dysplasia (mOS: 26.1mo, P=0.001) and invasive cancer (mOS: 25.0mo, P<0.001) were associated with significantly worse OS compared to no or low-grade dysplasia. Patients who underwent conversion of high-risk margins (high-grade or invasive cancer) to a low-risk margin (low-grade or no dysplasia) after intraoperative frozen section had significantly superior OS compared to those with a high-risk neck margin on final pathology (mOS: 76.9 vs. 26.1mo P<0.001). In IPMN-derived PDAC, normal epithelium or low-grade dysplasia at the neck have similar outcomes while pancreatic neck margins with high-grade dysplasia or invasive cancer are associated with poorer outcomes. Conversion of a high-risk to low-risk margin after intraoperative frozen section is associated with survival benefit and should be performed when feasible.

The Role of AI in Improving Surgical Outcomes

Artificial intelligence (AI) is transforming surgical procedures by improving precision, efficiency, and patient outcomes. This study investigates the role of artificial intelligence in the optimization of robotic-assisted surgeries, preoperative planning, and intraoperative decision-making. With the rise of machine learning algorithms trained on surgical data, AI can detect issues, increase safety, and supplement surgical teams’ capabilities. This review focuses on existing surgical practice challenges, the incorporation of AI into the operating theater, and the potential for AI-driven technologies to reduce human errors. The ethical concerns and future developments required for widespread AI usage in surgery are also addressed. Keywords: Artificial intelligence, surgical robots, machine learning, patient safety, preoperative planning.

Predictive model for intraoperative decision-making in video-assisted thoracoscopic lobectomy: optimizing chest drain placement for high-risk patients.

For years, it has been the common and widely accepted practice in thoracic surgery to place apical and basal drains after a lobectomy to completely drain the pleural cavity. With the development of thoracoscopic technology, it became apparent that the use of a single chest tube provided the same clinical results. However, sometimes tension pneumothorax occurs with the need for additional pleural drainage. The aim of this study was to develop a prognostic model to identify high risk patients intraoperatively and to insert additional pleural drainage to prevent the development of pneumothorax after video-assisted thoracoscopic surgery (VATS) lobectomy. This was a retrospective multicenter study of patients (registry data was analyzed) who underwent VATS lobectomy via a standardized multiport approach between 2014 and 2022. In all cases, a single drain was used postoperatively. We used a machine learning algorithm and data synthesis to expand patient selection according to Riley's method. A total of 418 cases were analyzed in this study. After determining the prognostically significant factors, we performed a binary logistic regression analysis using reverse step-by-step inclusion of variables according to the Akaike information criterion. After validation of the model by bootstrap (400 iterations) and with the original dataset, a nomogram with a specific point distribution for each risk factor was created. The rate of tension pneumothorax was 4.53% (n=66). The most significant variables associated with the need for additional drainage were adhesions, intraoperative lung suturing, fused interlobar fissure, enlarged intrapulmonary lymph nodes, chronic obstructive pulmonary disease (P<0.001). The C-index of the model was 0.957, the mean absolute calibration error was 0.6%, and the slope of the calibration curve was 0.959. A score of 26 points indicated a 95% risk of postoperative tension pneumothorax. The nomogram achieved good predictive performance for tension pneumothorax after minimally invasive lobectomy. High-risk patients could be identified, and additional drainage may be placed intraoperatively to reduce the risk of lung collapse in the postoperative period.

Intraoperative Intracranial Pressure Monitoring as an Intraoperative Guide During Operations for Relieving Elevated Intracranial Pressure

Intracranial pressure (ICP) is a well-established measure in managing not only traumatic brain injury but also nontraumatic intracranial bleeding or edema. When ICP increases despite nursing or medical management, ICP may be reduced via surgical measures. Deciding whether to perform a craniotomy vs. craniectomy (whether the bone flap is replaced or not, respectively) is commonly made intraoperatively following preoperative planning. While ICP monitoring (ICPm) is standard pre- and postoperatively, its intraoperative utility remains understudied. We conducted a study utilizing prospectively gathered and retrospectively analyzed data from 25 traumatic brain injury surgical decompression cases at a single center. All cases had intraoperative ICPm throughout surgery. Our findings indicate that ICPm significantly influenced real-time intraoperative decision-making, diverging from preoperative. These results bring forward the potential pivotal role of intraoperative ICPm in guiding surgical strategies for elevated ICP, suggesting a novel data-driven approach to intraoperative management of decompression surgery.

The Incidence of Radiologic Evidence of Sinusitis Following Endoscopic Pituitary Surgery: A Multi-Center Study.

Background: Endoscopic endonasal skull base surgery has become a viable alternative to open procedures for the surgical treatment of benign and malignant lesions in the sinonasal and skull base regions. As in sinus surgery, skull base surgery may cause crusting and posterior rhinorrhea, particularly when a nasoseptal flap is required for skull base reconstruction. Post-operative radiological sinonasal findings have been reported previously with no clear correlation with intraoperative decision-making. As in open surgery, endoscopic surgery is not standardized and there is variability in the intervention to assist with exposure and skull base repair. These modifications, including middle turbinate resection, nasoseptal flap, fat graft, and maxillary antrostomy have the potential for nasal morbidity. The aim of this study was to evaluate whether specific interventions during surgery or specific patient and tumor characteristics harbor a more significant risk of causing nasal morbidity post-operatively, as demonstrated by post-operative imaging. Methods: A retrospective analysis of all patients who underwent endoscopic endonasal skull base surgery for pituitary lesions at two major referral centers was performed. Data on demographic, clinical, and pathological features were collected, and pre- and post-operative imaging studies (computed tomography (CT) and magnetic resonance imaging (MRI)) were reviewed and scored according to the Lund-Mackay (LM) scoring system. Results: The study included 183 patients. Radiographic evidence of sinusitis was observed in 30 patients (LM score > 4) in post-operative imaging studies. Patients who underwent middle turbinectomy or nasoseptal flap were found to have significantly higher LM scores on follow-up imaging. A nasoseptal flap was found to be associated with an average increase in LM score of 1.67 points and middle turbinectomy with an average increase of 2.21 points. There was no correlation between tumor size and findings that were compatible with sinusitis on post-operative imaging. Conclusions: The findings of the present study suggest that endoscopic endonasal skull base surgery is associated with radiological evidence of sinusitis. Nasoseptal flap reconstruction and middle turbinectomy were strongly associated with radiographic sinusitis and should be judiciously performed during surgery. A clinical correlation is needed for further recommendations.

Fast intraoperative detection of primary CNS lymphoma and differentiation from common CNS tumors using stimulated Raman histology and deep learning.

Accurate intraoperative diagnosis is crucial for differentiating between primary CNS lymphoma (PCNSL) and other CNS entities, guiding surgical decision-making, but represents significant challenges due to overlapping histomorphological features, time constraints, and differing treatment strategies. We combined stimulated Raman histology (SRH) with deep learning to address this challenge. We imaged unprocessed, label-free tissue samples intraoperatively using a portable Raman scattering microscope, generating virtual H&E-like images within less than three minutes. We developed a deep learning pipeline called RapidLymphoma based on a self-supervised learning strategy to (1) detect PCNSL, (2) differentiate from other CNS entities, and (3) test the diagnostic performance in a prospective international multicenter cohort and two additional independent test cohorts. We trained on 54,000 SRH patch images sourced from surgical resections and stereotactic-guided biopsies, including various CNS tumor/non-tumor lesions. Training and test data were collected from four tertiary international medical centers. The final histopathological diagnosis served as ground-truth. In the prospective test cohort of PCNSL and non-PCNSL entities (n=160), RapidLymphoma achieved an overall balanced accuracy of 97.81% ±0.91, non-inferior to frozen section analysis in detecting PCNSL (100% vs. 78.94%). The additional test cohorts (n=420, n=59) reached balanced accuracy rates of 95.44% ±0.74 and 95.57% ±2.47 in differentiating IDH-wildtype diffuse gliomas and various brain metastasis from PCNSL. Visual heatmaps revealed RapidLymphoma's capabilities to detect class-specific histomorphological key features. RapidLymphoma is valid and reliable in detecting PCNSL and differentiating from other CNS entities within three minutes, as well as visual feedback in an intraoperative setting. This leads to fast clinical decision-making and further treatment strategy planning.

Effect of the cone-beam CT acquisition trajectory on image quality in spine surgery: experimental cadaver study

BACKGROUNDIntraoperative 3D imaging with cone-beam CT (CBCT) improves assessment of implant position and reduces complications in spine surgery. It is also used for image-guided surgical techniques, resulting in improved quality of care. However, in some cases, metal artifacts can reduce image quality and make it difficult to assess pedicle screw position and reduction. PURPOSEThe objective of this study was to investigate whether a change in CBCT acquisition trajectory in relation to pedicle screw position during dorsal instrumentation can reduce metal artifacts and consequently improve image quality and clinical assessability. STUDY DESIGNExperimental cadaver study. METHODSA human cadaver was instrumented with pedicle screws in the thoracic and lumbar spine region (Th11 to L5). Then, the acquisition trajectory of the CBCT (Cios Spin, Siemens, Germany) to the pedicle screws was systematically changed in 5° steps in angulation (−30° to +30°) and swivel (−25° to +25°). Subsequently, radiological evaluation was performed by 3 blinded, qualified raters on image quality using 9 questions (including anatomical structures, implant position, appearance of artifacts) with a score (1–5 points). For statistical evaluation, the image quality of the different acquisition trajectories was compared to the standard acquisition trajectory and checked for significant differences. RESULTSThe angulated acquisition trajectory significantly increased the score for subjective image quality (p<.001) as well as the clinical assessability of pedicle screw position (p<.001) with particularly strong effects on subjective image quality in the vertebral pedicle region (d=1.61). Swivel of the acquisition trajectory significantly improved all queried domains of subjective image quality (p<.001) as well as clinical assessability of pedicle screw position (p<.001). CONCLUSIONSIn this cadaver study, the angulation as well as the swivel of the acquisition trajectory led to a significantly improved image quality in intraoperative 3D imaging (CBCT) with a constant isocenter. The data show that maximizing the angulation/swivel angle towards 30°/25° provides the best tested subjective image quality and enhances clinical assessability. Therefore, a correct adjustment of the acquisition trajectory can help to make intraoperative revision decisions more reliably. CLINICAL SIGNIFICANCEThe knowledge of enhanced image quality by changing the acquisition trajectory in intraoperative 3D imaging can be used for the assessment of critical screw positions in spine surgery. The implementation of this knowledge requires only a minor change of the current intraoperative imaging workflow without additional technical equipment and could further reduce the need for revision surgery.

Surgical outcome of sinodural meningiomas

IntroductionMeningiomas located in the posterior fossa and involving the sinodural angle at the junction of the transverse and sigmoid sinuses are uncommon and present unique challenges due to their complex anatomical location. Despite their distinctive features, they are frequently categorized with tentorial meningiomas in the literature. Materials and methodsThis retrospective study conducted at a tertiary care center involved 64 patients with sinodural meningiomas who underwent surgical treatment between 2010 and 2023. The analysis covered demographics, clinical presentation, radiological characteristics, surgical approaches, histopathological findings, and outcomes. ResultsThe cohort predominantly comprised females (83 %) with a mean age of 47.64 years. Headache (92.2 %) and gait disturbances (62.5 %) were the most common presenting symptoms. Preoperative imaging showed sinus involvement in 57.8 % of cases, predominating Sindou’s type 1 and type 6. Gross total resection (Simpson grades 1–2) was achieved in 40.6 % of cases. Postoperative complications included pseudomeningocele (9.4 %), especially in patients with hydrocephalus. ConclusionSinodural meningiomas represent a distinct subset of posterior fossa tumors, necessitating meticulous preoperative planning and intraoperative decision-making regarding sinus management. The study underscores the importance of individualized surgical strategies and highlights the role of radiosurgery in managing residual disease effectively.

Influence of Diabetes Mellitus on Changes in Intra-Operative Decision Making in Coronary Artery Bypass Grafting

Background: We evaluated whether patients with diabetes mellitus experienced more surgical strategy changes than patients without diabetes when undergoing coronary artery bypass graft surgery utilizing a protocol for intraoperative high frequency ultrasound and transit-time flow measurement. Methods: Outcomes of coronary artery bypass grafting (CABG) patients with and without diabetes enrolled in the multicenter prospective Registry for Quality Assessment with Ultrasound Imaging and TTFM in Cardiac Bypass Surgery (REQUEST) study were retrospectively compared. The primary endpoint was frequency of intraoperative surgical strategy changes. We also evaluated the differences in patient characteristics and operative characteristics including graft configuration. Results: We compared 614 non-diabetic patients with 402 diabetic patients, among whom 128 were insulin dependent. Patients with diabetes had higher rates of surgical strategy change for the aortic component of the operation (10.2% vs. 6.4%, odds ratio (OR) = 1.67; 95% confidence interval (CI) = 1.06–2.65; p = 0.026). Surgical strategy changes related to in-situ conduits were more common in on-pump procedures in comparison to off-pump in diabetics (4.0% vs. 0%; p = 0.007). Diabetes was associated with less frequent use of bilateral internal mammary arteries (BIMA) (25.6% vs. 33.7%; p = 0.006), more frequent use of radial artery (31.3% vs. 16.9%; p &lt; 0.001) and multi-arterial configuration (48.3% vs. 39.9%, p = 0.009), and more total grafts (3.1 ± 1.1 vs. 2.8 ± 0.9; p &lt; 0.001). Conclusions: When performing isolated CABG on diabetic patients, surgeons were more likely to change surgical strategy for the aortic component of the operation based on high-frequency ultrasound (HFUS), and more likely to make a change related to in-situ conduits in on-pump procedures in diabetics. Among diabetic patients, there was less frequent use of BIMA, more frequent use of radial artery, more frequent multi-arterial configuration, and more total grafts.

Tumor spread through air spaces in lung cancer: prospective analysis of the accuracy of intraoperative frozen section examination.

To establish the accuracy of frozen section examination in identifying tumor spread through air spaces (STAS), as well as to propose a reproducible technical methodology for frozen section analysis. We also aim to propose a method to be incorporated into the decision making about the need for conversion to lobectomy during sublobar resection. This was a nonrandomized prospective study of 38 patients with lung cancer who underwent surgical resection. The findings regarding STAS in the frozen section were compared with the definitive histopathological study of paraffin-embedded sections. We calculated a confusion matrix to obtain the positive predictive value (PPV), negative predictive value (NPV), sensitivity, specificity and accuracy. The intraoperative frozen section analysis identified 7 STAS-positive cases that were also positive in the histopathological examination, as well as 3 STAS-negative cases that were positive in the in the histopathological examination. Therefore, frozen section analysis was determined to have a sensitivity of 70%, specificity of 100%, PPV of 100%, NPV of 90.3%, and accuracy of 92% for identifying STAS. Frozen section analysis is capable of identifying STAS during resection in patients with lung cancer. The PPV, NPV, sensitivity, and specificity showed that the technique proposed could be incorporated at other centers and would allow advances directly linked to prognosis. In addition, given the high accuracy of the technique, it could inform intraoperative decisions regarding sublobar versus lobar resection.

Endoscopic Transsphenoidal Drainage for Rathke Cleft Cyst With Sellar Xanthogranuloma - Successful Cyst Drainage and Prevention of Postoperative Cerebrospinal Fluid Leakage: 2-Dimensional Operative Video.

The etiology of sellar xanthogranuloma (SXG) remains unclear,1-5 and the surgical strategy for treating SXG is debatable. In this study, we present the surgical case of a symptomatic SXG associated with Rathke cleft cyst. The intraoperative decision to prevent postoperative cerebrospinal fluid (CSF) leakage and secure the drainage route is discussed. A 72-year-old woman presented with severe headaches, visual loss, and gradual enlargement of a cystic lesion on magnetic resonance imaging. The cyst compressed the chiasm upward. The cyst wall was partially thickened and contained a solid mass that was weakly enhanced after gadolinium administration. The endoscopic transsphenoidal cyst was drained, the solid tumor was partially removed for histological diagnosis, and the wide drainage orifice was secured. Intraoperatively, the cyst wall was widely open, but CSF leaked during manipulation of the solid tumor. The sellar floor was partially reconstructed by a multilayer technique to prevent postoperative CSF leakage. The wide cyst drainage route to the sphenoid sinus was also secured. Histologic diagnosis revealed SXG with ciliated columnar epithelium. No postoperative CSF leakage occurred, and the cyst continued to shrink. The patient's visual acuity improved, and pituitary function was preserved. If a CSF leak is identified intraoperatively in a case of secondary SXG associated with Rathke cleft cyst, a cystic fenestration with partial sellar reconstruction may reduce the likelihood of postoperative CSF leakage and ensure continuous drainage. Institutional Review Board approval was not required; The patient consented to the surgery and the publication of her images and surgical video.

Surgical Outcome After Distal Pancreatectomy With and Without Portomesenteric Venous Resection in Patients with Pancreatic Adenocarcinoma: A Transatlantic Evaluation of Patients in North America, Germany, Sweden, and The Netherlands (GAPASURG)

BackgroundPancreatic adenocarcinoma located in the pancreatic body might require a portomesenteric venous resection (PVR), but data regarding surgical risks after distal pancreatectomy (DP) with PVR are sparse. Insight into additional surgical risks of DP-PVR could support preoperative counseling and intraoperative decision making. This study aimed to provide insight into the surgical outcome of DP-PVR, including its potential risk elevation over standard DP.MethodsWe conducted a retrospective, multicenter study including all patients with pancreatic adenocarcinoma who underwent DP ± PVR (2018–2020), registered in four audits for pancreatic surgery from North America, Germany, Sweden, and The Netherlands. Patients who underwent concomitant arterial and/or multivisceral resection(s) were excluded. Predictors for in-hospital/30-day major morbidity and mortality were investigated by logistic regression, correcting for each audit.ResultsOverall, 2924 patients after DP were included, of whom 241 patients (8.2%) underwent DP-PVR. Rates of major morbidity (24% vs. 18%; p = 0.024) and post-pancreatectomy hemorrhage grade B/C (10% vs. 3%; p = 0.041) were higher after DP-PVR compared with standard DP. Mortality after DP-PVR and standard DP did not differ significantly (2% vs. 1%; p = 0.542). Predictors for major morbidity were PVR (odds ratio [OR] 1.500, 95% confidence interval [CI] 1.086–2.071) and conversion from minimally invasive to open surgery (OR 1.420, 95% CI 1.032–1.970). Predictors for mortality were higher age (OR 1.087, 95% CI 1.045–1.132), chronic obstructive pulmonary disease (OR 4.167, 95% CI 1.852–9.374), and conversion from minimally invasive to open surgery (OR 2.919, 95% CI 1.197–7.118), whereas concomitant PVR was not associated with mortality.ConclusionsPVR during DP for pancreatic adenocarcinoma in the pancreatic body is associated with increased morbidity, but can be performed safely in terms of mortality.

Assessment of the bony resection margin distance in bone-invasive oral cancer using laser-induced breakdown spectroscopy

ObjectivesInadequate resection margins of less than 5 mm impair local tumor control. This weak point in oncological safety is exacerbated in bone-infiltrating tumors because rapid bone analysis procedures do not exist. This study aims to assess the bony resection margin status of bone-invasive oral cancer using laser-induced breakdown spectroscopy (LIBS).Materials and methodsLIBS experiments were performed on natively lasered, tumor-infiltrated mandibular cross-sections from 10 patients. In total, 5,336 spectra were recorded at defined distances from the tumor border. Resection margins < 1 mm were defined as very close, from 1–5 mm as close, and > 5 mm as clear. The spectra were histologically validated. Based on the LIBS spectra, the discriminatory power of potassium (K) and soluble calcium (Ca) between bone-infiltrating tumor tissue and very close, close, and clear resection margins was determined.ResultsLIBS-derived electrolyte emission values of K and soluble Ca as well as histological parameters for bone neogenesis/fibrosis and lymphocyte/macrophage infiltrates differ significantly between bone-infiltrating tumor tissue spectra and healthy bone spectra from very close, close, and clear resection margins (p < 0.0001). Using LIBS, the transition from very close resection margins to bone-infiltrating tumor tissue can be determined with a sensitivity of 95.0%, and the transition from clear to close resection margins can be determined with a sensitivity of 85.3%.ConclusionsLIBS can reliably determine the boundary of bone-infiltrating tumors and might provide an orientation for determining a clear resection margin.Clinical relevanceLIBS could facilitate intraoperative decision-making and avoid inadequate resection margins in bone-invasive oral cancer.

Applications of Indocyanine Green (ICG) fluorescence in pediatric colorectal conditions

Postoperative success in pediatric colorectal surgery hinges on achieving adequate perfusion during complex reconstructive procedures. This review synthesizes findings from recent publications regarding the application of Indocyanine Green (ICG) in various surgical interventions for conditions such as Hirschsprung disease, anorectal malformations, cloacal reconstructions, and others.Preliminary evidence suggests that ICG fluorescence enhances intraoperative decision-making by improving vascular visualization and assessing tissue perfusion. Compared to conventional methods, ICG may offer superior evaluation of intestinal perfusion.While initial reports indicate a favorable safety profile for ICG use in pediatric patients, further prospective studies are needed to confirm these observations, quantify benefits, and assess its impact on surgical outcomes. By providing real-time perfusion data, ICG holds promise for enhancing surgical precision and improving patient outcomes in pediatric colorectal surgery.